Provider Demographics
NPI:1194044313
Name:WALLACE B MCLEOD III, INC
Entity Type:Organization
Organization Name:WALLACE B MCLEOD III, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SHAMBRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-424-0111
Mailing Address - Street 1:2216 N MARTIN LUTHER KING AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-2445
Mailing Address - Country:US
Mailing Address - Phone:405-424-0111
Mailing Address - Fax:
Practice Address - Street 1:2216 N MARTIN LUTHER KING AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-2445
Practice Address - Country:US
Practice Address - Phone:405-424-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK05538623602Medicaid
OK05538623602Medicaid